CONJUNCTIVITIS

K. MILLIKAN · 2024 · Case ID: 24000881

MIXED

Summary

The Veteran, who served in the U.S. Navy from March 1988 to February 1992, appeals the denial of a compensable rating for right eye recurrent erosion. The Board granted entitlement to an initial 10 percent rating for this condition, finding that the Veteran's symptoms of redness, pain, watering, and foreign-body sensation most closely approximated the symptoms addressed by Diagnostic Code (DC) 6018 for chronic conjunctivitis. Under both former and revised criteria, active conjunctivitis warrants a minimum 10 percent rating. The Board noted that while the Veteran's corrected distance vision remained 20/40 or better, preventing a rating based on visual impairment, and his self-treated episodes did not meet the definition of incapacitating episodes requiring clinic visits, the symptoms themselves warranted the 10 percent rating. The claim for an extraschedular rating in excess of 10 percent for the same condition was remanded for consideration by VA's Director of Compensation Service, as previous directives for this referral had not been followed. The Board found that further attempts to obtain examinations during flare-ups would be fruitless given the Veteran's history of self-treatment and the number of prior examinations.

Rationale

Symptoms approximated chronic conjunctivitis (DC 6018); Active disease warrants minimum 10% rating; Visual impairment and incapacitating episodes did not meet criteria for higher rating

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Diagnostic Code

6018

Docket No.

15-15 357

Full Decision Text

Citation Nr: 24000881
Decision Date: 01/05/24 Archive Date: 01/05/24

DOCKET NO. 15-15 357
DATE: January 5, 2024

ORDER

Entitlement to an initial 10 percent rating for right eye recurrent erosion is granted.

REMANDED

Entitlement to an extraschedular rating in excess of 10 percent for right eye recurrent erosion is remanded.

FINDING OF FACT

The Veteran's right eye recurrent erosion manifests in pain, watering, foreign-body sensation, and redness analogous to chronic conjunctivitis.

CONCLUSION OF LAW

The criteria for an initial 10 percent rating for right eye recurrent erosion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.79, Diagnostic Code (DC) 6009-6018.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served in the U.S. Navy from March 1988 to February 1992. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).

In January 2018, the Veteran testified at a Board hearing. A transcript of the hearing has been associated with the claims file.

This claim has been remanded a number of times. Initially, the Board remanded the claim for a VA examination and referral to the Director of Compensation for an extraschedular opinion. Thereafter, in November 2019, March 2021, and May 2022, the Board remanded for the Veteran to be afforded a VA examination during a flare-up of symptoms. At this point, the Veteran has participated in number VA examinations, but none have been held during an episode/flare-up of his right eye erosion syndrome. Given that the claim has been on appeal from 2013, the Board has attempted to obtain examinations during a flare up through 4 remands, the Veteran has not received any treatment during an episode/flare-up, and the Veteran has already participated in 7 eye examinations, the Board finds that continued attempts to remand for an examination during a flare-up would be fruitless.

1. Entitlement to an initial 10 percent rating for right eye recurrent erosion is granted.

The Veteran is seeking a compensable rating for his right eye recurrent erosion.

During his 2018 Board hearing, the Veteran testified that during flare-ups of his recurrent erosion his eye was cloudy/watery and difficult to see through. The episodes occur randomly, and without known causal factors. He described the recurrent erosion episodes as looking like "pink eye." The Veteran worked as a corrections officer, and due to his recurrent erosion, he missed work. He was unable to handle weapons, qualify for weapons, or do "tower" work during an episode. He testified that he took off work almost one day every month, sometimes more, due to his eye condition. He argued his right eye erosion resulted in incapacitating episodes because he had to miss work. The VLJ explained that the Veteran did not have incapacitating episodes as defined by the regulations in effect at that time, because he had not been prescribed bedrest by a physician. However, the Veteran's representative argued that the Veteran warranted a 10 percent rating for either his vision or his incapacitating episodes. The representative then cited medical evidence of decreased uncorrected distance vision.

Regulations

During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments.

A September 2013 rating decision granted entitlement to service connection for right eye recurrent erosion, with an initial noncompensable rating, effective June 12, 2012. The noncompensable rating was provided under DC 6009-6066. DC 6009 provides ratings for unhealed eye injuries, and DC 6066 relates to ratings for visual acuity. Evaluation of visual acuity is based on corrected distance vision with central fixation. 38 C.F.R. § 4.76(b)(1).

Under the former
claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments.

Under the former criteria, DC 6009 instructed to evaluate pursuant to the General Rating Formula for Diagnostic Codes 6000 through 6009 which directs to evaluate on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher evaluation. A Note following the General Rating Formula indicates that, for VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider.

Under the revised criteria, DC 6009 instructs to evaluate pursuant to the General Rating Formula for Diseases of the Eye which directs to evaluate on the basis of either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation. Note (1) indicates that, for the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. Note (3) indicates that, for the purposes of evaluating visual impairment due to a particular condition, refer to 38 C.F.R. § 4.75-4.78 and to § 4.79, DCs 6061-6091.

Both the former and revised criteria provide for consideration of visual impairment. The amendments made no substantive changes to how visual acuity is rated. With regard to visual field and muscle function examinations, the use of a Goldmann chart is no longer required. There are otherwise no substantive changes to how those types of visual impairment are rated.

As pertinent to this claim, the Board will also address the regulations related to chronic conjunctivitis, DC 6018.

Both the former and revised criteria distinguish active and inactive disease processes. Under the former criteria, an active disease process (with objective findings, such as red, thick conjunctivae, mucous secretion, etc.) is assigned a 10 percent rating. Under the revised criteria, an active disease process is rated pursuant to the General Rating Formula for Diseases of the Eye, with a minimum rating of 10 percent. For an inactive disease process, both the former and revised criteria instruct to evaluate based on residuals, such as visual impairment and disfigurement (DC 7800).

Factual Background

Although prior to the period on appeal, the Board notes that a December 16, 2003 private treatment record included the Veteran's report that his right eye seemed blurrier and would become bloodshot a couple times per month, lasting a couple days. He denied burning, itching, or discharge. He stated his last eye examination was "as a child." His uncorrected distance vision was 20/20 bilaterally. He was given Genteal gel to treat his symptoms.

A private optometry record from February 1, 2012 included the Veteran's report that his vision was "good." He reported an injury to his right eye in service, with occasional hemorrhages to the eye, approximately every six months. His uncorrected vision was 20/30 right and 20/20 left. His cornea, conjunctiva, and sclera were clear on evaluation.

Following a November 2012 VA eye examination, the diagnosis was recurrent erosion of the right eye. He reported an in-service injury from a finger scratch to the eye. Since onset, he had 4 episodes per year of pain and redness of the right eye. On testing, his corrected distance vision was 20/40 or better. The Veteran did not have diplopia. On physical evaluation, the Veteran had two small areas of basement membrane duplication on his right cornea. He otherwise had a normal slit lamp/external examination, and a normal internal eye examination. The examiner selected that the Veteran had a visual field defect, but then selected that the Veteran did not have a contraction of visual field, loss of visual field, or scotoma. The examiner found that the Veteran's cornea condition did not result in decreased visual acuity or other visual impairment, and that his condition did not case scarring or disfigurement. The examiner selected that he had not had any incapacitating episodes in the prior 12 months. In the functional impairment section, the examiner noted that the Veteran reported episodes of pain and redness for 21 years. The examiner found that he had basement membrane duplication which is the usual anatomical substrate for recurrent erosion syndrome. An associated visual field chart does not demonstrate contraction or loss of visual field and a scotoma is not identified.

During a May 9, 2014 eye examination, the Veteran's recurrent erosion syndrome right eye resulted in corrected distance vision of 20/40 or better bilaterally. He did not have diplopia. On physical evaluation, he had a small area of basement pigment dotting in the right cornea. He otherwise had a normal slit lamp/external examination and a normal fundus/internal examination. The examiner found that there was no visual field defect, scarring, or disfigurement. The examiner selected that the Veteran's right eye condition did not impact his ability to work. At the time of the examination, the Veteran's right eye recurrent erosion was quiescent. His visual field was normal on testing and not reduced. Additionally, the examiner noted that recurrent erosion does not affect visual fields.

On his March 2015 substantive appeal, the Veteran stated that the findings regarding his recurrent erosion were wrong. He argued that he did have visual impairment and incapacitating episodes of "more than a week a couple times a year."

A May 13, 2016 private medical record noted the Veteran had requested a statement regarding his right eye corneal erosion and how it affected his job. He reported flare-ups every 3 months (on average), with symptoms of red, painful eyes, lasting up to 5 days. He described a "film" over his right eye vision and a foreign body sensation. His corrected distance at that time was 20/25 right and 20/20 left.

A May 13, 2016 private record included the Veteran's report of episodes of recurrent erosion that occurred at varying frequency. He worked as a corrections officer and stated that it was difficult to do his job during a flare-up/episode. He requested a letter stating this for his job. On evaluation, his right cornea had a non-wetting area around the limbus. He did not have any other physical findings. He was to continue with artificial tears and to start using Genteal gel at bedtime for the next six months. It is unclear form the record when the Veteran's initial prescription for Genteal gel from 2003 was discontinued such that it was restarted with this provider.

A May 13, 2016 letter from a private optometrist, entitled "Reason for disability," noted the Veteran's recurrent corneal erosion of the right eye could flare up at any time without warning and cause pain, discomfort and blurred vision. A similarly worded letter by a physician's assistant is also of record from May 16, 2016.

An August 2016 eye examination included that the Veteran had tried a variety of remedies for his recurrent erosion syndrome (right eye), but none had stopped the recurrence. His corrected distance vision was 20/40 or better bilaterally. He did not have diplopia or visual field impairment. See August 18, 2016 addendum. Slit lamp/external and fundus/internal examination were both normal. The examiner found that the Veteran's right eye erosion syndrome was quiescent at the time of the examination. He was between episodes at the time of the examination. He did not have scarring or disfigurement. He had not had any incapacitating episodes (old definition requiring prescribed bedrest) in the prior 12 months. The examiner selected
variety of remedies for his recurrent erosion syndrome (right eye), but none had stopped the recurrence. His corrected distance vision was 20/40 or better bilaterally. He did not have diplopia or visual field impairment. See August 18, 2016 addendum. Slit lamp/external and fundus/internal examination were both normal. The examiner found that the Veteran's right eye erosion syndrome was quiescent at the time of the examination. He was between episodes at the time of the examination. He did not have scarring or disfigurement. He had not had any incapacitating episodes (old definition requiring prescribed bedrest) in the prior 12 months. The examiner selected that his condition did not impact his ability to work.

A January 24, 2018 private medical record noted that the Veteran's corrected distance vision was 20/25+ (both eyes together). His uncorrected right vision was 20/50+2. This uncorrected vision was cited by the Veteran's representative during his January 2018 Board hearing as evidence that the Veteran's vision was worsening. As such, the claim was remanded for an updated examination. However, the Veteran's uncorrected vision cannot be used to provide an increased rating. The record did not include his corrected right visual acuity.

A May 4, 2018 VA treatment record included the Veteran's report that he had occasional bloodshot red eyes. No other symptoms were reported. These occurred monthly, lasting 2 to 3 days since active duty (1991).

During a May 21, 2019 VA primary care physician visit the physician asked the Veteran when he last had an eye examination (optometrist). The Veteran reported he was unsure, but he denied issues and declined a referral.

A June 12, 2019 VA eye examination diagnosed bilateral dry eye syndrome. At the time of the examination, he was not having a flare-up of symptoms. He was being treated with artificial tears/Genteal tears. The Veteran described the impact of his condition as his eyes turned red (looked like pink eye), impaired vision, and he had a foreign body sensation. His corrected distance vision was listed as 20/20 or better for both eyes. He did not have diplopia or visual field impairment. On slit lamp examination, he had dry eye syndrome of both conjunctiva/sclera. He otherwise had a normal slit lamp/external examination and a normal fundus/internal examination. The examiner selected that the Veteran had bilateral dry eye syndrome which began in 1991-2. He used over the counter artificial tears, and the condition did not result in decreased visual acuity or other visual impairment. He did not have scarring or disfigurement. Regarding incapacitating episodes, the examiner found that the Veteran had not had any in the prior 12 months under the new definition requiring a clinic visit for treatment purposes. The examiner found that his eye condition did not impact the Veteran's ability to work. The examiner found that dry eye was a more accurate diagnosis than recurrent erosion as recurrent erosion was a manifestation/symptom of dry eye syndrome. Recurrent corneal erosion occurred when dry eye is left untreated and there is any type of trauma to the eye. As the Veteran was being treated with eye drops, his cornea was kept moist, and erosion was not present at the time of the exam.

On March 18, 2022, the Veteran participated in another VA eye examination. He was diagnosed with recurrent corneal erosion of the right eye, and he reported regular episodes of eye pain and redness approximately 10 to 15 times per year that lasted 4 to 7 days, before resolving on its own. He did not have symptoms at the time of the examination, his most recent episode was 3 weeks prior. He was currently treating his eyes with thick, over-the-counter lubricating drops nightly for the past year. He used the treatment more during a flare-up. He previously tried Visine, but it intensified the stinging. His corrected distance vision was 20/20 bilaterally. He did not have diplopia or visual field impairment. Slit lamp evaluation showed a small area of basement membrane irregularity near superior limbus on the right cornea. Otherwise, he had a normal slit lamp/external evaluation and fundus/internal evaluation. The examiner selected that the Veteran had right keratopathy (damage to the cornea) that did not result in a decrease in visual acuity or other visual impairment. The Veteran did not have scarring or disfigurement associated with his eye condition. The examiner selected that the Veteran had not had any incapac
-up. He previously tried Visine, but it intensified the stinging. His corrected distance vision was 20/20 bilaterally. He did not have diplopia or visual field impairment. Slit lamp evaluation showed a small area of basement membrane irregularity near superior limbus on the right cornea. Otherwise, he had a normal slit lamp/external evaluation and fundus/internal evaluation. The examiner selected that the Veteran had right keratopathy (damage to the cornea) that did not result in a decrease in visual acuity or other visual impairment. The Veteran did not have scarring or disfigurement associated with his eye condition. The examiner selected that the Veteran had not had any incapacitating episodes (new definition) in the prior 12 months. Regarding the impact of his eye condition on his ability to work, the Veteran reported he had to call in sick due to intense eye pain and poor vision in his shooting eye. He was unable to perform tower duty during a flare-up, and the pain itself was "incapacitating" at times preventing him from working in any capacity.

In the remarks section, the examiner noted that the Veteran had photo-documented 5 flare-ups from February to August 2020. However, he had not sought medical care because he had previously been told that all he could do was use lubrication and no other treatment was available. However, the examiner noted that the severity of the flare-ups described indicated he may have benefited from a bandage contact lens or amniotic membrane to provide pain relief and assist in healing. The Veteran stated that if he had been aware of treatment options were available to him, then he would have sought treatment for these episodes. Copies of the photos are not contained in the record.

On June 10, 2022, the Veteran again participated in a VA eye examination. He was diagnosed with right eye cornea erosion and bilateral dry eye syndrome. He brought in photos documenting his red eyes; they were dated in February, March, April, June, and July 2020. He stated his last episode of corneal erosion was one month prior. During the recent episode there was a gush of water in the right eye, he had to use a tissue to soak up the water. When asked about the frequency of his episodes, the Veteran reported that the episodes varied. He called out of work 6 to 15 times per year depending on the year. In the last 8 months, he called out of work 4 times. He usually self-treated at home because he had been told that there was nothing else he could do. He also reported that he was unable to open his eye due to the pain during an episode. He had no symptoms at the time of the examination.

On evaluation, the Veteran's corrected distance vision was 20/20 or better bilaterally. He did not have diplopia or visual field impairment. On slit lamp evaluation, the Veteran had moderate bilateral meibomian gland dysfunction (MGD). Otherwise, his slit lamp/external evaluation and fundus/internal evaluation was normal. His MGD did not result in visual impairment. The Veteran's recurrent corneal erosions resulted in visual impairment, described as watery/fuzzy vision during an episode. He did not have scarring or disfigurement and had not had any incapacitating episodes (new definition) in the prior 12 months. Regarding functional impact, the Veteran reported having to call in sick due to eye pain/decreased vision/watery eyes. He was unable to use a weapon when he was on tower duty during an episode. He called off work 4 times since November 2021 due to eye pain. He had no active recurrent corneal erosion during the examination. He also had moderate bilateral dry eye that was manifesting as moderate meibomian gland dysfunction of both eyes. Having dry eye syndrome made the Veteran more susceptible to recurrent corneal erosion in his right eye.

On August 15, 2022, the examiner was asked to discuss the frequency and severity of the Veteran's erosion episodes. The examiner estimated the frequency of the Veteran's flare-ups as 1 to 2 times every 1 to 3 months. The severity ranged from mild to moderate. With speculation, an episode would last from several hours to a whole day. There was no functional loss during a mild episode. During a moderate episode, the Veteran was unable to perform his work duties for a day. He reported calling out 6 to 15 days per year depending on the severity. The examiner based his speculations on the Veteran's reports, photographs shown during the examination, and history of evaluations. The examiner based
, 2022, the examiner was asked to discuss the frequency and severity of the Veteran's erosion episodes. The examiner estimated the frequency of the Veteran's flare-ups as 1 to 2 times every 1 to 3 months. The severity ranged from mild to moderate. With speculation, an episode would last from several hours to a whole day. There was no functional loss during a mild episode. During a moderate episode, the Veteran was unable to perform his work duties for a day. He reported calling out 6 to 15 days per year depending on the severity. The examiner based his speculations on the Veteran's reports, photographs shown during the examination, and history of evaluations. The examiner based his estimate of severity from mild to moderate on the Veteran's self-treating his symptoms at home. The examiner could not provide better estimates because there was a deficiency in the record. As the Veteran self-treated his erosions, there were no medical records to review. In an August 22, 2022 addendum the examiner noted that his recurrent corneal erosion episodes were not incapacitating episodes as they were not severe enough to require treatment visits, and the Veteran had been self-treating at home.

A September 2022 medical opinion noted that the Veteran's MGD was not caused or aggravated by his recurrent corneal erosion. The rationale for these opinions was that MGD was due to inflammation of the eyelids, which can cause dry eye syndrome, and dry eye syndrome can aggravate corneal erosion. Additionally, MGD was an eyelid condition, and as corneal erosion was due to abnormal epithelial adhesions, it could not impact the eyelids.

On September 15, 2022, the Veteran again participated in an eye examination. He was diagnosed with bilateral dry eye syndrome, bilateral MGD, right recurrent corneal erosion, and right chalazion. He reported episodes of corneal erosion 1 to 2 times per month or once every 2 to 3 months. He had an episode the month prior. During an episode, his eye is very painful, and he cannot open his eye due to pain. At the time of the examination, he did not have any symptoms. Regarding the functional impact of the corneal erosion, the Veteran's ability to complete gun training for his job is compromised by his watery/fuzzy vision and pain. He calls out of work 6 to 15 times a year depending on the severity of his episodes. In the last 6 to 8 months, he called out of work 4 times. On evaluation, the Veteran's corrected distance vision was 20/20 or better. He did not have diplopia or visual field impairment. On slit lamp evaluation, the Veteran had moderate MGD of both eyelids, a right chalazion on the inferior palpebral conjunctiva, and bilateral decreased tear break up time (5 seconds). He had a normal fundus/internal eye evaluation. The examiner noted that the Veteran had recurrent corneal erosions due to having dry eye syndrome and MGD. His visual impairments were related to his right corneal erosion, dry eye syndrome, and MGD. His bilateral dry eye syndrome was treated with over-the-counter artificial tear drops. The Veteran's chalazion was caused by his MGD. This examiner also provided an opinion that the Veteran's MGD was not caused or aggravated by his service-connected corneal erosion because MGD is an inflammation of the eyelids and corneal erosion was due to abnormal epithelial adhesions on the cornea.

In the remarks section, the examiner noted that the Veteran's episodes of recurrent erosion ranged in severity from mild to moderate, with 6 to 8 episodes per year, sometimes more. The Veteran reported that in January 2022, he stayed home from work 6 times. He stated his episodes lasted from a couple days to up to a week but averaged 2 to 4 days. Generally, if he needed to take time off work due to the episodes it was for 1 or 2 days. The Veteran described active recurrent erosion episodes as resulting in watery red eyes, blurred vision, pain, and irritation. He stated he was unable to focus and "really see" during an episode. The functional impact of the symptoms was a limitation on driving, reading, working, and he was unable to go to the gun range at work.

Analysis

The Board finds that the Veteran's right eye recurrent corneal erosion symptoms of episodic redness, watering, blurred vision, foreign body sensation, and pain most closely approximated the symptoms addressed by DC 6018 for conjunctiv
4 days. Generally, if he needed to take time off work due to the episodes it was for 1 or 2 days. The Veteran described active recurrent erosion episodes as resulting in watery red eyes, blurred vision, pain, and irritation. He stated he was unable to focus and "really see" during an episode. The functional impact of the symptoms was a limitation on driving, reading, working, and he was unable to go to the gun range at work.

Analysis

The Board finds that the Veteran's right eye recurrent corneal erosion symptoms of episodic redness, watering, blurred vision, foreign body sensation, and pain most closely approximated the symptoms addressed by DC 6018 for conjunctivitis. This former criteria, DC 6018 provides a minimum 10 percent rating for active symptoms, such as red, thick conjunctivae, mucous secretion, etc. Under the revised criteria, DC 6018 directs to rate active disability under the General Rating Formula (for visual impairment or incapacitating episodes) with a minimum 10 percent rating. As such, a 10 percent rating is warranted for the entire period on appeal.

The Board notes that recurrent corneal erosions is a condition of the cornea and chronic conjunctivitis is associated with the conjunctiva, which are separate parts of the eye. However, the symptoms associated with the Veteran's corneal erosion closely match those of conjunctivitis. Indeed, the Veteran has described the symptoms and appearance of his corneal erosions as being similar to "pink eye," which is the lay term for conjunctivitis.

There is no specific diagnostic code for corneal erosions. Although DC 6009, for an unhealed eye injury, appears appropriate because the Veteran's corneal erosion began with a finger poke injury to the eye, his ongoing symptoms are better associated with those contemplated by DC 6018.

DC 6009 allows the Veteran to be rated for visual impairment or incapacitating episodes. During the period on appeal, the Veteran's corrected distance vision has remained 20/40 or better, which warrants a noncompensable rating. Examinations have not shown, and the Veteran has not complained of, diplopia or visual field impairment. The Board notes that the 2012 and 2016 examiners selected "yes" for if the Veteran had a visual field impairment, but then subsequently selected "no" for all visual field impairment options. The Board presumes this was an error in the creation of the documents (or possibly a function of a drop-down menu within the examination), as the accompanying visual field charts did not show a visual field impairment, a VA examiner noted that corneal erosion does not cause visual field impairment, and subsequent (numerous) examinations did not find visual field impairment. As such, a compensable rating based on visual impairment is not shown by the ongoing treatment records.

The Board notes that the Veteran's visual acuity has not been tested during a flare-up/episode of right eye corneal erosion. The Board has remanded the claim several times in the hopes of scheduling the Veteran for an examination during a flare-up/episode, but this has not been a fruitful pursuit over the years. The Veteran has provided various reports to providers and VA regarding the length of his episodes, which vary in both severity and frequency. Additionally, there are no private or VA treatment records during a flare-up/episode as the Veteran does not seek treatment during episodes. As such, whatever change in vision the Veteran has during an episode is unknown and cannot be estimated as visual acuity must be ascertained through testing. However, his visual acuity after an episode returns to a noncompensable severity. Indeed, one of his examinations occurred within weeks of an episode, and his vision remained 20/40 or better. As such, the Board finds that a compensable rating based on visual impairment is not warranted.

The Board additionally finds that a compensable rating is not warranted based on incapacitating episodes. Prior to May 2018, the Veteran was not prescribed bedrest to treat his episodes of recurrent corneal erosions. The Veteran rarely sought treatment for his eyes, and when he was seen by private providers, he was treated with Genteal gel or similar lubricants only. Normally, the Veteran self-treated with either prescribed or over-the-counter lubricants/artificial tears. After May 2018, the Veteran continued to self-treat his symptoms. He reported to VA examiners that he did not seek treatment because he had been informed that there was nothing that could be done other than to use the lubricating eye drops. The March 2022 examiner informed the Veteran that if his symptoms were severe
. Prior to May 2018, the Veteran was not prescribed bedrest to treat his episodes of recurrent corneal erosions. The Veteran rarely sought treatment for his eyes, and when he was seen by private providers, he was treated with Genteal gel or similar lubricants only. Normally, the Veteran self-treated with either prescribed or over-the-counter lubricants/artificial tears. After May 2018, the Veteran continued to self-treat his symptoms. He reported to VA examiners that he did not seek treatment because he had been informed that there was nothing that could be done other than to use the lubricating eye drops. The March 2022 examiner informed the Veteran that if his symptoms were severe, he could be treated with a bandage contact lens or amniotic membrane. However, even after being informed that there were treatment options, the evidence does not show that the Veteran sought treatment for any episodes after May 2022. According to the June and September 2022 examinations, the Veteran had episodes of recurrent erosion in May and August 2022. As the current definition of an incapacitating episode requires that the eye condition episode be severe enough to require a clinic visit for treatment purposes, and the evidence of record does not show that the Veteran saw a provider for treatment purposes from May 2018 onward, the Board finds that a compensable rating based on incapacitating episodes is not warranted.

The Board has also considered whether a greater rating may be available by rating analogous to another diagnostic code. To that extent, the former criteria for DC 6036 for corneal transplant, instructs to evaluate status post corneal transplant based on visual impairment. A 10 percent minimum rating is assigned if there is pain, photophobia, and glare sensitivity. DC 6036 is for the same anatomical region as the Veteran's corneal erosion (cornea), and the Veteran has pain during an episode. However, overall, the Veteran's symptoms more nearly approximate the symptoms generally associated with chronic conjunctivitis-redness, pain, foreign body sensation, discharge/watering. Additionally, DC 6036 would not provide a rating in excess of 10 percent, so the Veteran is not disadvantaged by the Board's choice to rate analogous to DC 6018.

The Board finds that the Veteran's right eye corneal erosion warrants an initial schedular 10 percent rating, and no higher, during the entire period on appeal.

REASONS FOR REMAND

1. Entitlement to an extraschedular rating in excess of 10 percent for right eye recurrent erosion is remanded.

The June 2018 Board decision included a directive to refer the Veteran's claim to the Director of Compensation Service for extraschedular consideration. A review of the claim does not show that this referral has occurred. Unfortunately, there has not been substantial compliance with the Board's previous remand directives regarding the issue. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998).

The matters are REMANDED for the following action:

Refer the Veteran's claim for an increased rating for corneal erosion of the right eye to VA's Director of Compensation Service for extraschedular consideration.

K. MILLIKAN

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board M.H. Stubbs

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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